Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review

Cheung, Zoe B.; Xiao, Ryan; Forsh, David A.

doi:10.1007/s00402-020-03701-2

Cited by 14 publications

(7 citation statements)

References 24 publications

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“…The transfusion rate also is consistent with the range reported in the literature, though it falls on the lower end. 23,25,28,29,31,32 No significant difference in EBL and change in hemoglobin/hematocrit were found; however, although EBL is a standard measure of intraoperative hemostatic status, it has limited validity because of the subjective nature of EBL and the decreased efficacy of EBL reporting, particularly in percutaneous procedures versus open procedures. Early surgical management within 48 hours of their last preoperative DOAC dose was significantly associated with decreased postoperative transfusion rate.…”

Section: Discussionmentioning

confidence: 98%

“…They reported an incidence of blood transfusion in anticoagulated patients ranging from 9.0% to 58.0% and in nonanticoagulated patients ranging from 7.7% to 39.3%. 22,[26][27][28][29][30][31] A recent study by Anazor et al 32 demonstrated that among 131 patients with hip fracture, those on DOACs have greater EBL and have greater need for intraoperative and postoperative transfusions than patients who are not anticoagulated when treated with 24 hours. Contrastingly, Kolodychuk et al and Levack et al 23,25 demonstrated no increased bleeding risk or postoperative anemia among patients with hip fracture on DOACs This study of 205 hip fracture surgery patients on direct oral anticoagulants demonstrated that 66% of patients on DOACs were delayed more than 48 hours after last DOAC dose, with a median time to surgery of 51 hours from last dose (IQR 39-67) with 28.7% requiring a transfusion.…”

Section: Discussionmentioning

confidence: 99%

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Use of Direct-Acting Anticoagulants (DOAC) Among Hip Fracture Patients Is Not an Indication to Delay Surgical Intervention.

Brameier,

Tischler,

Ottesen

et al. 2023

Journal of Orthopaedic Trauma

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OBJECTIVES: To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours. METHODS: Design: Retrospective cohort study. Setting: Three academic Level 1 trauma centers. Patient Selection Criteria: Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. Outcome Measures and Comparisons: Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS: Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65–100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2–20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05–5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons). CONCLUSIONS: Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Use of Direct-Acting Anticoagulants (DOAC) Among Hip Fracture Patients Is Not an Indication to Delay Surgical Intervention.

Brameier,

Tischler,

Ottesen

et al. 2023

Journal of Orthopaedic Trauma

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“…Literature to date has reported mixed data on transfusion need in DOAC patients, with no clear relationship to time to surgery 7,8 . In our overall sample, blood transfusions were needed more often when time to surgery increased.…”

Section: Discussionmentioning

confidence: 99%

Early Hip Fracture Surgery in Patients taking Direct Anticoagulants improves Outcome.

Rommens

Baranowski

Wagner

2023

Preprint

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The increasing numbers of already endemic hip fractures in the elderly taking anticoagulants is a growing concern for daily surgical practice. Ample evidence demonstrates decreased morbidity and mortality in the general population when surgery is performed at the earliest possibility. Direct anticoagulants are relatively new drugs that can cause increased perioperative bleeding. Current guidelines propose stopping the drug to allow for elimination before performing elective surgery. Optimal management in urgent hip surgery is presently based on expert opinion with arbitrary cut-offs. In this study, we investigated whether patients taking direct anticoagulants would benefit from early surgical treatment, regardless of the timing since last intake. 340 Patients were included in the analysis, of which 59 took direct anticoagulants. The primary outcomes were time to surgery, postoperative transfusion rate, postoperative hemoglobin decrease, length of postoperative in-hospital stay (LOPS), revision rate and complication rate (medical and surgical). Our findings showed that the anticoagulated group was fit for discharge earlier when operated on within 24 hours. (p = 0.0167). Postoperative transfusion and medical complication rate tended to be lower when the operation was performed earlier. Revision rate due to hematomas were higher in the direct anticoagulant group without a relationship to time to surgery. Simple linear regression could not determine a relationship between postoperative hemoglobin change and time to surgery. We suggest that directly anticoagulated patients needing hip fracture surgery must be considered for early surgery regardless of last intake.

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“…The number of studies examining the complications and outcomes of anticoagulated patients receiving hip arthroplasty subsequent to experiencing an acute hip fracture is limited [ 34 ]. Overall, 28% of the patients in our study cohort needed at least one RBCT during or after surgery.…”

Section: Discussionmentioning

confidence: 99%

Early Surgical Care of Anticoagulated Hip Fracture Patients Is Feasible—A Retrospective Chart Review of Hip Fracture Patients Treated with Hip Arthroplasty within 24 Hours

Pankratz

Cintean

Boitin

et al. 2022

JCM

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Anticoagulative medication such as antiplatelet drugs (PAI, acetylsalicylic acid and direct platelet aggregation inhibitors), vitamin-K-antagonist Warfarin (VKA) or direct oral anticoagulants (DOAC) are common among hip fracture patients, and the perioperative management of these patients is a rising challenge in orthopaedic trauma. Our objective was to determine the effect of oral anticoagulation in patients receiving early endoprosthetic treatment within 24 h after their admission. For the period from 2016 to 2020, a retrospective chart review of 221 patients (mean age 83 ± 7 years; 161 women and 60 men) who were treated either with hemi- (n = 209) or total hip arthroplasty (n = 12) within 24 h after their admission was performed. We identified 68 patients who took PAI, 34 who took DOAC and 9 who took VKA medications. The primary outcome measures were the transfusion rate and the pre- and postoperative haemoglobin (Hb) difference. The secondary outcome measures were the in-patient mortality and the rate of postoperative haematomas that needed operative treatment. A logistic/ordinal regression was performed considering the related variables to prevent cofounding occurring. The mean time to surgery was significantly longer for the DOAC and VKA groups when they were compared to the controls (none 14.7 ± 7.0 h; PAI 12.9 ± 6.7 h; DOAC 18.6 ± 6.3 h; VKA 19.4 ± 5.5 h; p < 0.05). There was no difference in the preoperative Hb level between the groups. Overall, 62 patients (28%) needed blood transfusions during the in-patient stay with an ASA classification (p = 0.022), but the type of anticoagulative medication was not a significant predictor in the logistic regression. Anticoagulation with DOAC and grouped surgery times were positive predictors for a higher Hb difference in the patients who did not undergo an intraoperative blood transfusion (n = 159). Postoperative haematomas only occurred in patients taking anticoagulative medication (four cases in PAI group, and three cases in DOAC group), but the logistic regression showed that the anticoagulative medication had no effect. The in-patient mortality was significantly influenced by a high ASA grade (p = 0.008), but not by the type of anticoagulative medication in patients who were treated within 24 h. We conclude that the early endoprosthetic treatment of the anticoagulated hip fracture patient is safe, and a delayed surgical treatment is no longer justifiable.

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Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review

Cited by 14 publications

References 24 publications

Use of Direct-Acting Anticoagulants (DOAC) Among Hip Fracture Patients Is Not an Indication to Delay Surgical Intervention.

Use of Direct-Acting Anticoagulants (DOAC) Among Hip Fracture Patients Is Not an Indication to Delay Surgical Intervention.

Early Hip Fracture Surgery in Patients taking Direct Anticoagulants improves Outcome.

Early Surgical Care of Anticoagulated Hip Fracture Patients Is Feasible—A Retrospective Chart Review of Hip Fracture Patients Treated with Hip Arthroplasty within 24 Hours

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